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BY DARWIN B. NELSON, PhD KAYE WELCH NELSON, EdD & MAXINE E. TRENT, MS

08 MIND NEWS

USING THE RELATIONSHIP SKILLS MAP (RSM)

26 THE SELF-PSYCHOLOGICAL VIEW OF OBSESSIVE COMPULSIVE DISORDER TREATING THE TORMENTED SELF

52 SOMATIC EXPERIENCING

NEUROSCIENTIFIC APPROACH TO ATTACHMENT TRAUMA BY JACQUELINE A. CARLETON, PhD & JAQLYN L. GABAY, HHC, LDC SPRING 2012

51 BOOK REVIEWS 66 SHORT STORY BY JAMES MCADAMS

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36 TWO KEY NUTRIENTS FOR THE TREATMENT OF MAJOR DEPRESSIVE DISORDER BY RYAN HARRISON

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40 FORT BLISS: LEADING THE WAY

12 CHAIR’S CORNER:

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TODAY & TOMORROW

BY DANIEL J. REIDENBERG, PsyD, FAPA, BCPC, MTAPA

FOR INTEGRATIVE MEDICINE IN THE MILITARY

45 NATURAL REMEDIES: PEPPERMINT OIL NCCAM CLEARINGHOUSE

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46 GUIDED MEDITATION: BED, AT LAST BY EVE ELIOT

BY IRENE ROSENBERG JAVORS, LMHC, MEd, DAPA

68 PRACTICE MANAGEMENT:

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BY RONALD HIXSON, PhD, LPC, LMFT, BCPC

72 CHAPLAIN’S COLUMN:

RESOLUTIONS vs. COMMITMENTS

BY CHAPLAIN DAVID J. FAIR, PhD, CHS-V, CMC

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Psychotherapy Annals of

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Become a member of the American Psychotherapy Association®. We provide mental health professionals with the tools necessary to be successful and build stronger practices. Annual membership dues are $165. For more information, or to become a member, call us toll-free at (800) 592-1125 or visit www.americanpsychotherapy.com. 2012 EDITORIAL ADVISORY BOARD Debra L. Ainbinder, PhD, NCC, LPC, BCPC Janeil E. Anderson, LCPC, BCPC, DBT Kelley A. Armbruster, MSW, FAPA Diana L. Barnes, PsyD, LMFT Cherie J. Bauer, MPS Phyllis J. Bonds, MS, NCC, LMHC Sabrina Caballero, LCSW, DAPA Stacy L. Carter, PhD, BCPC Susanne Caviness, PhD, LMFT, LPC Peter W. Choate, MSW, DAPA, MTAPA Linda J. Cook, LCSW, CRS, DAPA, BCETS John Cooke, PhD, LCDC, FAPA Caryn Coons, MA, LPC Clifton D. Croan, MA, LPC, DAPA Catherine J. Crumpler, MA, LPC, BCPC Charette Dersch, PhD, LMFT David R. Diaz, MD Carolyn L. Durr, MA, LPC Adnan M. Farah, PhD, BCC, LPC Patricia Frank, PsyD, FAPA Natalie H. Frazier, PhD, LPC Sabrina Friedman, EdD, CNS-BC, FNP-C Robert R. Gerl, PhD Rebecca Godfrey-Burt Sam Goldstein, PhD, DAPA Jacqueline R. Grendel, MA, LPC, BCPC Richard A. Griffin, EdD, PhD, ThD, DAPA Yuh-Jen Guo, PhD, LPC, NCC Lanelle Hanagriff, MA, LPC, FAPA Ray L. Hawkins, PhD, LPC, AAMFT Gregory B. Henderson, MS Douglas Henning, PhD Mark E. Hillman, PhD, DAPA Elizabeth E. Hinkle, LPC, LMFT, NBCC Ronald Hixson, PhD, LPC, DAPA, BCPC Judith Hochman, PhD Antoinette C. Hollis, PhD Irene F. Rosenberg Javors, MEd, DAPA Gregory J. Johanson, PhD

Laura W. Kelley, PhD Gary Kesling, PhD, FAAMA, FAAETS C.G. Kledaras, PhD, ACSW, LCSW Michael W. Krumper, LCSW, DAPA Ryan LaMothe, PhD P. K. Frederick Low, MAppPsy, MSc, BSocSc, DAPA Edward Mackey, PhD, CRNA, MS, CBT Frank Malone, PsyD, LMHC, LPC, FAPA Beth McEvoy-Rumbo, PhD Thomas C. Merriman, EdD, SBEC (Virginia) Ginger Arvan Metcalf, MS, RN William Mosier, EdD, PA-C Natalie H. Newton, PhD, DAPA Kim Nimon, PhD Donald P. Owens, Jr., PhD Thomas J. Pallardy, PsyD, BCPC, LCPC, CADC Larry H. Pastor, MD, FAPA Richard Ponton, PhD Joel G. Prather, PhD, MS, BCPC, Helen D. Pratt, PhD Ahmed Rady, MD, BCPC, FAPA, DABMPP Daniel J. Reidenberg, PsyD, FAPA, CRS Arnold Robbins, MD, FAPA Arlin Roy, MSW, LCSW Maria Saxionis, LICSW, LADC-I, CCBT, CRFT Alan D. Schmetzer, MD, FAPA, MTAPA Paul Schweinler, MDiv, MA, LMHC, DAPA Bridget H. Staten, PhD, CRC, MS, MA Suzann Steadman, PsyD Ralph Steele, BCPC Moonhawk R. Stone, MS, LMHC Mary E.Taggart, LPC Patrick O.Thornton, PhD Mary A.Travis, PhD, EdS, MA, BS Charles Ukaoma, PsyD, PhD, BCPC, DAPA Lawrence M.Ventline, DMin Melinda L. Wood, LCSW, DAPA Cecilia Zuniga, PhD, BCPC

Annals of Psychotherapy & Integrative Health (ISSN 1535-4075) is published quarterly by the American Psychotherapy Association®. Annual membership for a year in the American Psychotherapy Association® is $165.The views expressed in Annals of Psychotherapy & Integrative Health® are those of the authors and may not reflect the official policies of the American Psychotherapy Association. Abstracts of articles published in Annals of Psychotherapy & Integrative Health® appear in e-psyche, Cambridge Scientific Database, PsycINFO, InfoTrac, Primary Source Microfilm, Gale Group Publishing’s InfoTrac Database, Galenet, and other research products published by the Gale Group. Contact us: Publication, editorial, and advertising offices at 2750 E. Sunshine St., Springfield, MO 65804. Phone: (417) 823-0173, Fax: (417) 823-9959, E-mail: editor@americanpsychotherapy.com. Postmaster: Send address changes to American Psychotherapy Association®, 2750 E. Sunshine St., Springfield, MO 65804. © Copyright 2011 by the American Psychotherapy Association. All rights reserved. No part of this work may be distributed or otherwise used without the expressed written consent of the American Psychotherapy Association®.

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EXECUTIVE ADVISORY BOARD CHAIR: Daniel J. Reidenberg, PsyD, FAPA, MTAPA, CRS MEMBERS: Peter W. Choate, PhD, MSW, DAPA, MTAPA Frances A. Clark-Patterson, PhD Clifton D. Croan, MA, LPC, FAPA Gerald L. Dahl, MSW, PhD Natalie H. Frazier, PhD, LPC Donald E. Goff, PhD, MTAPA, DAPA Ron Hixson, PhD, LPC, DAPA, BCPC Robert E. McCarthy, PhD, LPC, MTAPA Mary Helen McFerren Morosko Casseday, MA, LMFT, BCPC Kenneth Miller, PhD, BCPC Chrysanthe L. Parker, JD Stan Sharma, PhD, JD Wayne E.Tasker, PsyD, DAPA, BCPC

CONTINUING EDUCATION The American Psychotherapy Association’s sister organization, American College of Forensic Examiners International (ACFEI), provides continuing education credits for accountants, nurses, physicians, dentists, psychologists, psychiatrists, counselors, social workers, and marriage and family therapists. ACFEI is an approved provider of continuing education by the following: Accreditation Council for Continuing Medical Education National Association of State Boards of Accountancy National Board for Certified Counselors California Board of Registered Nursing American Psychological Association California Board of Behavioral Sciences Association of Social Work Boards American Dental Association (ADA CERP) Diplomate status with the American Psychotherapy Association® is recognized by the National Certification Commission. For more information on recognitions and approvals, please visit www.americanpsychotherapy.com

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Become a member of the American Association of Integrative MedicineSM. AAIM promotes the development of integrative medicine, which is the medicine of the 21st century. Annual membership dues are $165. For more information, or to become a member, call us toll-free at (877) 718-3053 or visit www.aaimedicine.com 2012 EDITORIAL ADVISORY BOARD Martin Alpert, MS, DC Rolando Arafiles, MD Eleanor Barrager Maggie Bloom Brenda Brown, PhD, ND Phillip Carlyle, MD Dean Cosgrove Zhaoming Chen, MD, PhD, MS, FAAIM Debra Dallas, MS, MIFHI Lynn Demartini, DSH-P, RN, LMT Kenneth Dennis, PhD David Getoff Cindy Griffin, DSH-P, DIHom Christine Gustafson, MD

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Mind News

Eating Fish Reduces Risk of Alzheimer’s Disease, Study Finds

, … n a l o P D u l l o ’ Y u f o I n Y ps to Thet It Helriend! Bu ve a F Ha

People who eat baked or broiled fish on a weekly basis may be improving their brain health and reducing their risk of developing mild cognitive impairment (MCI) and Alzheimer’s disease, according to a study presented November 30, 2011 at the annual meeting of the Radiological Society of North America (RSNA). “This is the first study to establish a direct relationship between fish consumption, brain structure, and Alzheimer’s risk,” said Cyrus Raji, MD, PhD, from the University of Pittsburgh Medical Center and the University of Pittsburgh

any people look forward to the New Year for a new start on old habits. While you are more likely to do something if you plan it in advance, research funded by the Economic and Social Research Council (ESRC), shows that partnering up or planning with someone can really boost the likelihood of sticking to your resolutions. This finding suggests that ‘buddy schemes’ could make a big difference to people following dieting plans or health programs and could be integrated into government well-being initiatives. “Specific plans regarding when, where, and how a person will act, have been termed ‘implementation intentions,” explains Professor Mark Conner from the Institute of Psychological Science at the University of Leeds. “We already know that these kinds of plans can be really effective. You set up cues that prompt your planned behaviour – ‘if I walk to work on Monday, then I will jog home’, ‘if I feel hungry before lunch, then I will eat an apple, not a chocolate bar.’ ” But research by Professor Conner and his colleagues, Dr Andrew Prestwich and Dr Rebecca Lawton from the University of Leeds, has now demonstrated that this effect can be made even stronger if you get other people – friends, family, and colleagues – involved too.

School of Medicine. “The results showed that people who consumed baked or broiled fish at least one time per week, had better preservation of gray matter volume on MRI in brain areas at risk for Alzheimer’s disease.” Radiological Society of North America (2011, November 30). Eating fish reduces risk of Alzheimer’s disease, study finds. ScienceDaily. Retrieved January 5, 2012, from http://www.sciencedaily.com/releases/2011/11/111130095257.htm

TINNITUS DISCOVERY

COULD LEAD TO NEW WAYS TO STOP THE RINGING: Their new findings, published onRetraining the Brain Could Reanimate Areas That Have Lost Input from the Ear

Economic & Social Research Council (2012, January 4). If you plan, then you’ll do… but it helps to have a friend. ScienceDaily. Retrieved January 5, 2012, from http://www.sciencedaily.com/releases/2012/01/120104111906.htm

SPRING 2012

Neuroscientists at the University of California, Berkeley, are offering hope to the 10 percent of the population who suffer from tinnitus – a constant, often highpitched ringing or buzzing in the ears that can be annoying, and even maddening, and has no cure.

Annals of Psychotherapy & Integrative Health®

line in the journal Proceedings of the National Academy of Sciences, suggest several new approaches to treatment, including retraining the brain, and new avenues for developing drugs to suppress the ringing. University of California - Berkeley (2011, September 12). Tinnitus discovery could lead to new ways to stop the ringing: Retraining the brain could reanimate areas that have lost input from the ear. ScienceDaily. Retrieved January 5, 2012, from http:// www.sciencedaily.com /releases/ 2011/09/110912144247.htm

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BLOGGINGSOCIAL

NEUROSCIENTISTS PINPOINT SPECIFIC

May Help Teens Dealing With Social Distress

Blogging may have psychological benefits for teens suffering from social anxiety by improving their self-esteem and helping them to relate better to their friends, according to new research published by the American Psychological Association. “Research has shown that writing a personal diary and other forms of expressive writing are a great way to release emotional distress and just feel better,” said the study’s lead author, Meyran Boniel-Nissim, PhD, of the University of Haifa, Israel. “Teens are online anyway, so blogging enables free expression and easy communication with others.” Maintaining a blog had a stronger positive effect on troubled students’ well-being than merely expressing their social anxieties and concerns in a private diary, according to the article published online in the APA journal, Psychological Services®. Opening the blog up to comments from the online community intensified those effects. Although cyberbullying and online abuse are extensive and broad, we noted that almost all responses to our participants through blog messages were supportive and positive in nature,” said the study’s co-author, Azy Barak, PhD, “We weren’t surprised, as we frequently see positive social expressions online in terms of generosity, support, and advice. American Psychological Association (2012, January 4). Blogging may help teens dealing with social distress. ScienceDaily. Retrieved January 5, 2012, from http://www.sciencedaily.com/releases/2012/01/120104115104.htm

Dreaming Takes

the Sting out of Painful Memories, Research Shows

They say time heals all wounds, and new research from the University of California, Berkeley indicates that time spent in dream sleep can help us overcome painful ordeals. UC Berkeley researchers have found that during the dream phase of sleep, also known as REM sleep, our stress chemistry shuts down and the brain processes emotional experiences and takes the edge off of difficult memories. These findings offer a compelling explanation as to why people with posttraumatic stress disorder (PTSD), such as war veterans, have a hard time recovering from distressing experiences and suffer recurring nightmares. They also offer clues into why we dream. University of California - Berkeley (2011, November 23). Dreaming takes the sting out of painful memories, research shows. ScienceDaily. Retrieved January 5, 2012, from http://www.sciencedaily.com/ releases/2011/11/111123133346.htm

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DIFFICULTIES IN PEOPLE WITH

AUTISM People with autism process information in unusual ways and often have difficulties in their social interactions in everyday life. While this can be especially striking in those who are otherwise high functioning, characterizing this difficulty in detail has been challenging. Now, researchers from the California Institute of Technology (Caltech) have isolated a very specific difference in how high-functioning people with autism think about other people, finding that – in actuality – they don’t tend to think about what others think of them at all. This finding, described online this week in the Proceedings of the National Academy of Sciences, sheds light on what researchers call “theory of mind” abilities – our intuitive skill for figuring out what other people think, intend, and believe. One key aspect of such abilities in terms of social interactions is to be able to figure out what others think of us – in other words, to know what our social reputation is. It is well known that social reputation usually has a very powerful influence on our behavior, motivating us to be nice to others. California Institute of Technology (2011, October 11). Neuroscientists pinpoint specific social difficulties in people with autism. ScienceDaily. Retrieved January 5, 2012, from http://www.sciencedaily.com/releases/2011/10/111011102006.htm

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SUCCESS FILES

fast facts for busy counselors By Wendy Briggs For decades bullying was considered a normal part of growing up and going to school. However, in recent years public opinion about bullying has changed. Bullying is no longer viewed as a “school” problem but rather a community problem. Government statistics show that 32% of middle and high school students report being victims of bullying (National Center for Education Statistics, 2011). Some sources claim the numbers to be even higher. The problem has become so prevalent that on March 9, 2011 President Obama convened a day-long White House Conference on Preventing Bullying (Hall, 2011) and announced the launch of an official U.S. Government website: www.stopbullying.gov. With one out of three children being bullied, chances are at some point in your career you will counsel or treat patients who have been directly or indirectly affected by bullying. Knowing the basics of bullying can greatly increase a therapist’s effectiveness in working with those patients and their families.

32%

of middle and high school students report being victims of bullying

SPRING 2012

Annals of Psychotherapy & Integrative Health®

bullying basics:

Types of Bullying

direct bullying:

—physical attacks like punching, shoving, kicking, hitting, and destruction of property; verbal abuse like name-calling, teasing, verbal threats, and obscene gestures. This behavior is more often seen in boys.

indirect bullying:

—verbal bullying, such as saying mean or untrue things, or spreading rumors; social bullying such as ignoring someone, manipulating friendships, enlisting friends to assault someone else, and daring others to do dangerous things upon threat of exclusion. This is more often seen in girls.

17%

cyber bullying:—sharing inappropriate pictures of someone, posing as someone else to spread rumors or lies, or sending harassing messages.

According to a survey conducted by the National Education Association’s Nationwide Study of Bullying, the most common form of bullying reported to school staff was verbal bullying being reported by 59% of students. Cyber-bullying and sexting were the least likely to be reported at only 17%. Social or relational bullying were reported by 50% of students and physical bullying by 39% (Bradshaw, Waasdorp, O, Gulemetova & Henderson, 2011). Because bullying often goes unreported, the actual numbers are unknown.

Consequences of Bullying Research shows that bullying has serious and lasting effects for all involved. According to www.stopbullying.gov, bullying can have the following effects:

Victims: Adolescents who are bullied may experience the following: depression and anxiety, increased thoughts of suicide, health complaints, decreased academic achievement and school participation, and skipping or dropping out of school. They may be more likely to lash out through violent ways; these thoughts and feelings may persist into adulthood. Bullies: Adolescents who bully others have a higher risk of abusing alcohol and other drugs, are more likely to be violent, to engage in sexual activity, to become involved in criminal activity, and to be abusive to others.

Bystanders: Adolescents who witness episodes of bullying may have increased use of alcohol and drugs, increased mental health problems, and are more likely to miss school. Some research suggests that bullying may also affect the climate of schools and, indirectly, the ability of all students to learn to the best of their abilities. www.americanpsychotherapy.com

Bully Prevention and Intervention Efforts Studies have been conducted on the different types of bully prevention programs used in schools worldwide. The Campbell Collaboration published a review of several school-based programs that gives an extensive overview of the effectiveness of 44 different programs. Their findings show that, “overall, school-based anti-bullying programs are effective in reducing bullying and victimization (being bullied). On average, bullying decreased by 20%–23% and victimization decreased by 17%–20%” (Farrington & Ttofi, 2009). Solutions to bullying must be implemented for long term results and consist of system- and community-wide efforts. Research suggests that zero tolerance policies as well as “three strike” rules are ineffective. One of the most widely used and successful programs has been the Olweus Bullying Prevention Program. “The intervention program is built on four key principles. These principles involve creating a school, and ideally, a home environment characterized by: (1) warmth, positive interest, and involvement from adults; (2) firm limits on unacceptable behavior; (3) consistent application of non-punitive, non-physical sanctions for unacceptable behavior and violation of rules, and (4) adults who act as authorities and positive role models” (American Psychological Association, 2004).

Bullying and the Law According to the U.S. Department of Education website, “forty-five states have already passed laws addressing bullying or harassment in school. Ultimately state officials will determine whether new or revised legislation and policies should be introduced to update, improve, or add bullying prevention provisions” (Duncan, 2010). A federally funded school is responsible for addressing harassment incidents about which it knows, or reasonably should have known. The Department of Education’s Office for Civil Rights (OCR) enforces statutes that prohibit discrimination on the basis of race, color, national origin, sex, or disability (Ali, 2010). Other federal, state, and local laws impose additional obligations on schools, such as prohibiting discrimination on the basis of religion or sexual orientation. It would be a good idea to review the statutes of your state to determine what protections they afford the students in your area. Healthcare providers can offer support to families in the form of tips and training for parents, therapy for victims and bullies themselves, and connecting families with government agencies who can help, especially when civil rights have been violated. This translates into healthier children, which in turn means a healthier community and a brighter future.

School Policies on Bullying Therapists and counselors should be familiar with the policies used by local schools and colleges. Knowing how the school handles bullying incidents can help therapists better serve patients and their families. While the U.S. Department of Education, along with other government agencies, are in the process of developing key strategies to support efforts to prevent bullying in U.S. schools, there are no official policies in place (Duncan, 2010). You can access examples of policies used by different states on the U.S. Department of Education website (http:// www2.ed.gov/policy/gen/guid/secletter/101215.html) by downloading the Microsoft Word document enclosed in the December 16, 2010, “Dear Colleagues Letter.” The Department of Education also plans to update their website to include recommended key strategies for preventing bullying. Anti-bullying policies will vary from state to state and from school to school. That’s why it is important to contact the schools in your area to discover the specific policies and procedures they use. Schools may post their bullying policies and program information on their official website.

References: Ali, R. (2010, October 26). Dear Colleague Letter: Harassment and Bullying. Retrieved Hall, M. (2011, March 09). White House conference tackles bullying. USA Today. Retrieved from http://www.usatoday.com from the U.S. Department of Education’s Office for Civil Rights Web site: http://www2. ed.gov/about/offices/list/ocr/letters/colleague-201010.pdf National Center for Education Statistics. American Institute for Research. U.S. Department of Education. (2011, August) Student reports of bullying and cyberAmerican Psychological Association. (2004, October 29). School bullying is nothing new, bullying: results from the 2009 school crime supplement to the national crime but psychologists identify new ways to prevent it. American Psychological Association victimization survey by Jill DeVoe and Christina Murphy. Retrieved December Web site. Retrieved from http://www.apa.org/research/action/bullying.aspx 27, 2011 from the National Center for Education Statistics Web site: http://nces. Bradshaw, C. P., Waasdorp, T. E., O, L. M., Gulemetova, M., & Henderson, R. D. National ed.gov/pubs2011/2011336.pdf Education Association, Research Department. (2011). Findings from the national education association’s nationwide study of bullying: Teachers’ and education support pro- Olweus, D. (1993). Bullying at school: What we know and what we can do. NY:Blackwell. fessionals’ perspectives. Retrieved from National Education Association website: http:// www.nea.org/home/Findings-from-the-NEAs-Nationwide-Study-of-Bullying.htm United States Department of Education. (2010). Anti-Bullying Policies: Examples Duncan. A. (2010, December 16). Key Policy Letters from the Education Secretary and Deputy Secretary. U.S. Department of Education Web site: http://www2.ed.gov/policy/ gen/guid/secletter/101215.html

of Provision in State Laws. Key Policies Letters from the Education Secretary and Deputy Secretary. Retrieved from the U.S. Department of Education Web site: http://www2.ed.gov/policy/gen/guid/secletter/101215.html as an enclosed MS Word document.

Farrington, D. P., Ttofi, M. M. School-Based Programs to Reduce Bullying and VictimizaUnited States Department of Health and Human Services. Department of Education. Campbell Systematic Reviews 2009:6 10.4073/csr.2009.6 tion. Department of Justice. (2011, March) Effects of Bullying. Retrieved DeFleming, M and Towey, K, eds. Educational Forum on Adolescent Health: Youth Bullying. cember 27, 2011 from the Department of Health and Human Services Web site: May 2002. Chicago: American Medical Association. Retrieved from http://www.amawww.stopbullying.gov assn.org/ama1/pub/upload/mm/39/youthbullying.pdf

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CHAIR’S CORNER

Today Tomorrow

Why both today AND tomorrow are so important to your clients. By Daniel J. Reidenberg, PsyD, FAPA, CRS, BCPC, MTAPA 12

SPRING 2012

Annals of Psychotherapy & Integrative Health®

e have all heard the saying, “Time heals all wounds,” and for some this is true, while for others it is not. For some events in life this seems to hold more truth than others. Whether you are talking with someone about grief, fear, or excitement, in the end, “time passes.” It never stops, not even for a second. The word time itself implies movement and change. Plain, simple, and thankfully; time goes by. Think of your client who comes in and is filled with anxiety about a conversation they are planning to have with their spouse. Their attention is distracted, and you can not keep them focused. They might be so filled with anxiety that they are behaviorally agitated and restless in your office. Regardless of how brilliant your insights and suggestions are, they are thwarted by their thoughts of “that won’t work!” or “you don’t know him like I do.” Next, think of another client who is plagued with hallucinations or delusions. They cannot get through the torment of the voices in their heads. These voices seem to speak louder and louder as the day goes by, but nothing helps; not music or art, not walking or talking; nothing www.americanpsychotherapy.com

“Yesterday is history. Tomorrow is a mystery. Today is a gift. That is why it is called the present.” Alice Morse Earle

dampens the messages they are hearing. Paranoia fills their minds with unanswerable, illogical fears that you can not resolve for them. Something bad is going to happen, although they don’t know when, where, or how. Time spent with you seems to be time spent fighting demons that only medications can fight. Finally, think of the client that cannot see through the darkness of the moment right in front of them. Nothing really matters to this client. They have no energy, no interest in anything, no desires. They don’t want to eat, as nothing tastes good. They want to sleep, but they really don’t care about that anymore than they do about what is on television. Life is filled with only doom and gloom, negativity, hopelessness, and helplessness. Your words of hope, encouragement, and positive reinforcement for even the smallest of miracles, go unnoticed. In each of these cases both today and tomorrow are very important. Today, they must deal with the reality that is in front of them. Regardless of the reasons for what is happening to them, today holds something that they have to accept and address, even if that means they do it tomorrow. As their therapist, health care professional, nutritionist, etc., if you are fortunate enough to see them on this day, you will need to address what is impacting them the most. If you fail to do that, the rest of your work together, at least for that day, quite possibly could be of no benefit to your patient. So always try to start your time with a client by checking in with them to find out how they are doing that day. Think back to how many times you have heard a colleague talk about spending 50 minutes with a client, and then the client finally discloses something significant that is not only on their mind, but is requiring all of their attention. When inquiring, make sure to ask about thoughts, feelings, and behaviors (as appropriate) to have a full picture of where they are when they are with you. Once you have established a basis for your session/time together, you can move on to other things they want to talk about, and/or parts of their treatment with you, or keep going with the current concerns that they have; but also don’t miss this opportunity you have with them to work on the things about today that can be meaningful and helpful to them. For example, you may choose to try and work with clients that are anxious by working on relaxation techniques. You could engage them in a conversation about stress management, help them build coping skills, teach resiliency, or help them learn how to track and monitor their anxiety. Today also offers your client a chance that is only here right now. (800) 592-1125

While this moment might be uncomfortable, or worse, it is important for them to realize that it won’t always be this way. Nothing stays the same forever, and you can remind them of this while also helping them find ways to appreciate the fact that it has been worse for them in the past, and yet they have made it through. Conversely, if they have never felt like they do at this moment in your office, how would they know what it might be like tomorrow? And that brings us to: if today is so important, then why is tomorrow so important too? Simply put: because tomorrow is. Since there is no escaping that there will be a tomorrow, it provides each of us with a golden opportunity. The opportunity is, and can be, whatever we make it to be. It might be just the same as today, or it might be 100% opposite of today. Tomorrow might be nothing like we expected it to be, or it could be exactly as we thought it would be. The point is that it will be something, and I often find people are either so afraid of what it could be, or they are so determined to make sure it isn’t what they don’t want it to be, that they struggle to accept it for what it is. Think of how many things you can do with “tomorrow.” You can talk with your clients about how different from today it might be, and what feelings they have that may or may not be the same as today. You can engage them in a plan that might move them from where they are right now, to someplace else. In the three examples offered earlier, your anxious client might be able to rate themselves two points lower in anxiety following the conversation with their spouse because it wasn’t as bad as they feared it would be; the client suffering with hallucinations and delusions might have had another day for their neuroleptics to work, and they can watch television today when they couldn’t the day before; and your client living in the depths of despair might see the sunrise outside and feel like they can go on, even if just for one more day. Help them to see what they can’t, don’t want to, or are afraid to. Give them reasons to get through today so they can reach tomorrow. In doing this, you will have helped them keep living. I think the most important thing about tomorrow is the fact that there is no avoiding it; there is only a chance to be a part of it. If tomorrow turns out to be just like today, your clients should be reminded that no two days are ever exactly the same. You can help them live through the moments of life, and even when they are not in your office with you, they will be better able to cope with all that life has to offer. In the end… “Yesterday is history. Tomorrow is a mystery. Today is a gift. That is why it is called the present.” Alice Morse Earle

ABOUT THE AUTHOR DANIEL J. REIDENBERG, PsyD, FAPA, CRS, BCPC, MTAPA, is the chair of the American Psychotherapy Association’s Executive Advisory Board and has been a member since 1997. He is a Fellow and Master Therapist of the American Psychotherapy Association and executive director of Suicide Awareness Voices of Education (SAVE) in Minneapolis, Minnesota. Contact him with your thoughts at dreidenberg@save.org. Annals of Psychotherapy & Integrative Health®

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CE ARTICLE: 1.5 CE Credits

Developing Resiliency 14

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www.americanpsychotherapy.com

By Darwin B. Nelson, PhD, Kaye Welch Nelson, EdD, and Maxine Trent, MS, LPC, LMFT

Using

p i h s n o i t a l e R the

skills map (rsm) with

n i s e l p u o c Military high stress

s t n e m n o r i v en Abstract

Skills: (800) 592-1125

This article examines the use of the Relationship Skills Map (RSM) as a positive assessment and reflective learning model for developing the core resiliency skills that protect and enhance the marital relationships of active duty military couples. The RSM provides scale-specific measurement of 10 operationally defined resiliency skills that are significantly related to relationship satisfaction and adjustment, effective and healthy communication, experiential intelligence (constructive thinking), and personal well-being. Congruent validation studies with the Dyadic Adjustment Inventory, the NEO and the Constructive Thinking Inventory (CTI) are briefly presented to clarify and expand the meaning and interpretation of RSM scale scores. The RSM has found to be a valuable and practical tool for experienced clinicians and serves as an efficient foundation and focus in relationship enhancement and marital therapy services with highly stressed military couples served by the Scott & White Military Homefront Services Program. Annals of Psychotherapy & Integrative Health速

SPRING 2012

CE CE ARTICLE: ARTICLE: 1.5 1.5 CE CE Credits Credits

he Scott & White Military Homefront Services’ operations are housed in Killeen, Texas, the home of Fort Hood (U.S. Army)—the epicenter of military deployments, the front and back door to the Middle East. The forward-mechanized battle group model embraced by the Army for the Global War on Terror has required every-other-year deployments (12-15 month separations) for those married military members. Currently at Fort Hood there are 50,000 active duty officers and enlisted personnel. According to the 2008 Department Of Defense (DOD) profile of the military community, 55.1% of all active duty military members are married. A majority (70.1%) of officers and over half (52.2%) of enlisted personnel reportedly are married. In addition, 6.7% of DOD active duty members are in dual-military marriages. The Army has the largest number of dual-military marriages at 4.9%. Military couples facing frequent deployments of long duration experience high and destructive levels of distress. Long periods of physical separation involving one or both partners places high levels of stress on marital relationships. The couples often do not have the time and energy resources to benefit from couples therapy and extended counseling. The Scott & White Military Homefront Services’ counselors have counted on the RSM to provide an effective and efficient foundation and focus for building resilience skills in these marital relationships.

ct e t o r p maintain

The use of the RSM as a practical, preventive intervention for increasing resiliency skills with military couples before, during, and after deployment has been a primary means of service delivery for the therapists in the Scott & White Military Homefront Services Program. The RSM was selected as the measure to quantify the specific resiliency skills that each individual couple member would develop, strengthen, or enhance. The Homefront therapist used the RSM as a reflective learning tool to assist couples in identifying their current strengths and targeting specific resiliency skills to learn and develop. A collaborative action plan for resiliencyskills development was co-created by the therapist and the couple. The RSM provides a cohesive language in therapy and a cognitive model for healthy relationship skills development. This language became the foundation for an environment of empowerment and enhancement, a positive focus for the development of healthy relationship skills before, during, and after deployment. The military community has been exhausted by the past eight years of wartime conflict and the accelerated tempo of deployments. The design and implementation of a practical and preventive intervention program to develop resiliency skills that military couples could use to protect, maintain, and strengthen their marital relationships was the primary program focus. The Scott & White Military Homefront Services Program provides individual, marital, and family therapy services that are free, unlimited, and confidential, serving Operation Enduring Freedom (Afghanistan) or Operation Iraqi Freedom (Iraq) personnel and their families. Homefront, which is grant funded, also provides resilience workshops and educational internships. From January 2008 to July 2010 the program provided 7,117 patient contacts.

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This article is approved by the following for 1.5 continuing education credits: This organization, The American College of Forensic Examiners International approval number 1052, is approved as a provider for continuing education by the Association of Social Work Boards 400 South Ridge Parkway, Suite B, Culpepper, VA 22701. www.aswb.org. ASWB Approval Period: 09/15/2010 to 09/15/2013. Social workers should contact their regulatory board to determine course approval. Social workers will receive 1.5 continuing education clock hours in participating in this course. The American College of Forensic Examiners International is an approved provider of the California Board of Behavioral Sciences, approval PCE 1896. Course meets the qualification for 1.5 hours of continuing education credit for MFTs and/or LCSWs as required by the California board of Behavioral Sciences. The American College of Forensic Examiners International is an NBCC-Approved Continuing Education Provider (ACEP™) and may offer NBCC-approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program. The American Psychotherapy Association® provides this continuing education credit(s) for Diplomates and certified members, who we recommend obtain 15 credits per year to maintain their status. Learning Objectives 1. Define reliliency skills from a research standpoint. 2. Utilize a new relationship assessment instrument that is valid, reliable and appropriate for applied clinical practice 3. Demonstrate the relationship of resiliency skills and scale specific measures provided by the Relationship Skills Map (RSM)

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KEYWORDS: Resiliency Skills, Relationship Skills Map, Healthy Relationship Skills, Emotional Intelligence Skills TARGET AUDIENCE: The article may be of interest to therapists, counselors and mental health professionals who design and deliver brief, preventive intervention programs focused on developing resiliency and coping skills. The specific focus is on developing healthy relationship skills that positively buffer stress and build resiliency. PROGRAM LEVEL: Basic DISCLOSURES: none PREREQUISITES: none

Background of the Problem Wolin and Wolin (1993) define resiliency as “the capacity to rise above adversity and forge lasting strengths in the struggle.” Epstein (1993) points out that resilient children “became precocious, constructive thinkers with a problem oriented approach to living, an accepting attitude toward themselves and others, and an optimistic and hopeful attitude about the future.” Constructive thinking (Epstein’s central construct) is seen as a prerequisite to resilient attitudes and behaviors. Adolescents and adults who survive in extremely difficult conditions develop coping skills and display these characteristics: accepting of self, self-confident, flexible and adaptable, accepting and understanding of others, optimistic and a positive attitude towards life, independent in thoughts and actions, realistic and takes reasonable risks, resilient (bounces back quickly after frustrations and adversity), reaches out to others and accepts appropriate help, maintains hope and a personal sense of purpose. Resiliency skills were operationally defined in this project as the RSM constructive thinking skills of self-esteem, stress (800) 592-1125

management, assertion, empathy, comfort, positive influence, goal setting, time management (self-management), decision making (problem solving), commitment ethic, and intimacy. Anger and anxietymanagement skills were linked to the RSM scale measures of Aggression and Deference and a program focus on building the resiliency skill of emotional self-control. The RSM scale measurements of Relationship Satisfaction and Change Orientation were used as estimates of relationship satisfaction and openness to change. The Relationship Skills Map (RSM) was selected as the positive self-assessment instrument to actively engage the couples in exploring, identifying, and understanding their current relationship behaviors and to serve as a cognitive/behavioral model for resiliency skills training. The RSM scales are significantly correlated with constructive thinking patterns (Cox, 2010), and constructive thinking skills are prerequisite to developing resiliency skills. The 10 RSM skill scales were used as the program model for building resiliency skills in the marital relationships of military couples facing frequent

and long-term deployments. The program focus was on emotional learning for relationship enhancement with an emphasis on building identified and couple-specific resiliency skills.

Purpose The purpose of this program was to assist military couples in exploring, identifying, and understanding the role of resiliency skills in protecting and strengthening their marital relationships during the high-stress situations arising from frequent and longterm deployments. Program therapists were introduced to the applications and limitations of the RSM, and guidelines were established for its use. The RSM provided scale-specific measures of 10 constructive thinking skills that were used as operational definitions for the resiliency skills emphasized in the program and as a measure of relationship health and satisfaction. The RSM scale definitions have been expanded and clarified by congruent validation studies with traditional measures of personality, emotional intelligence, and relationship satisfaction and adjustment (Cox, 2010). The RSM scale definitions that follow were provided to the program therapists, and experiential learning activities were designed to involve the participants in relationship skills development. The 10 RSM skill scales that follow were operationally defined as “resiliency skills,” and these research-derived skill definitions were developed based on the congruent validation studies with the scale measures provided by the NEO, CTI, and Dyadic Adjustment Scale. The NEO (Costa and McCrae, 1985) is a widely accepted measure of the “Big 5” personality factors constituting “normal” personality. The Constructive Thinking Inventory (Epstein, 2001) is a measure of emotional (experiential) intelligence and provides a measure of the central construct in Cognitive Experiential Self Theory (CEST), Global Constructive Thinking (GCT). The Dyadic Adjustment Scale (Spanier, 2001) is an accepted measure of relationship satisfaction and adjustment. By establishing the congruent validity of the RSM with these instruments, the meaning of the RSM scales were expanded and redefined as follows:

Annals of Psychotherapy & Integrative Health®

SPRING 2012

CE ARTICLE: 1.5 CE Credits 1. Self-Esteem (SE)

2. Interpersonal Assertion (IA)

Self-esteem skills are extremely important at a personal and relationship level. Your score on this scale is a reflection of how you are currently evaluating your worth as a person. Positive self-esteem (skill strength) is an indication that you like and value how you are as a person. A low score (skill strength) on this scale indicates that you may be out of touch with your strengths as a person and currently focused on negative aspects of your attitudes and behavior. The RSM Self-Esteem scale is significantly and positively correlated with the NEO scales of Conscientiousness (r = .44**) and Extraversion (r = .33*) and significantly and negatively correlated with Neuroticism (r = -.42**). RSM Self-Esteem is significantly and positively related to relationship satisfaction and adjustment as measured by the DAS (r = .66**). RSM Self-Esteem is significantly and positively correlated with Global Constructive Thinking (r = .43**), Emotional Coping (r = .38**), and Behavioral Coping ( r = .41**) as measured by the Constructive Thinking Inventory (CTI).

Your score on this scale indicates your current level of skill in communicating and solving problems with your partner. A high score (skill strength) indicates that you see yourself communicating in a straightforward and direct manner with your partner. A skill change on this scale may indicate that you are not currently communicating assertively with your partner. Assertive communication is a key relationship skill that makes it possible to communicate strong feelings in a respectful and constructive way to your partner. Check your scores on Aggression and Deference to identify your primary and secondary communication styles. RSM Interpersonal Assertion (IA) is significantly and positively correlated with the NEO scales of Extraversion (r = .42**) and Conscientiousness (r = .45**) and significantly and negatively correlated with Neuroticism (r = -.42**). RSM IA is significantly and positively correlated with relationship satisfaction and adjustment (r = .47**) as measured by the DAS. IA on the RSM is significantly and positively correlated with Behavior Coping (r = .33*), Action Orientation (r = .26*) and Conscientiousness (r = 39**) as measured by the CTI.

INTERPRETATION: Self-Esteem as measured by the RSM is significantly related to healthy personality, relationship satisfaction and adjustment, and global constructive thinking.

INTERPRETATION: Interpersonal Assertion (IA) as measured by the RSM is an action of conscientiousness important to relationship satisfaction and adjustment and behavioral coping.

3. Interpersonal Comfort (IC)

4. Empathy (E)

Your score on this scale indicates your skill in judging appropriate emotional and physical distance in your relationship. Skill strength would indicate an ability to express feelings appropriately and spontaneously and to be comfortable, self-assured, and relaxed with your partner. Skill change would suggest discomfort or awkwardness in your current relationship and a hesitancy or reluctance to seek closeness with your partner. RSM Interpersonal Comfort (IC) is significantly negatively correlated with Neuroticism (r = -.55**) and significantly positively related to Conscientiousness (r = .52**) as measured by the NEO. The RSM scale IC is significantly positively correlated with relationship satisfaction and adjustment (r = .74**) as measured by the DAS. The RSM IC scale is significantly positively correlated with Global Constructive Thinking ( r = .44**) and all other positive thinking patterns measured by the CTI.

Your score on this scale reflects your sensitivity to the feelings and thoughts of your partner. Skill strength indicates that you see yourself accurately understanding and responding to the feelings, thoughts, and behaviors of your partner (being a good listener). Skill change indicates difficulty in understanding thoughts, feelings, and behaviors from your partnerâ&#x20AC;&#x2122;s point of view. RSM Empathy (E) is significantly and positively correlated with relationship satisfaction and adjustment (r = .68**) as measured by the DAS. The RSM Empathy (E) scale seems to be more a measure of feeling sensitivity rather than the skill of accurate empathy.

INTERPRETATION: The Interpersonal Comfort (IC) scale of the RSM is significantly related to healthy personality, relationship satisfaction and adjustment, and global constructive thinking.

5.Interpersonal Influence (II) Your score on this scale reflects your perceived skill and ability to impact your partner in positive ways. Skill strength indicates a positive and nonmanipulative influence in your relationship with your partner. A skill change on this scale may indicate a hesitancy to let your partner know what you really want to do about relationship decisions (lack of confrontation and negotiation skills). RSM Interpersonal Influence (II) is significantly positively correlated to Conscientiousness as measured by the NEO (r = .38*) and the CTI (r = .27*).

INTERPRETATION: Interpersonal Influence (II) as measured by the RSM is related to positive action initiated in the relationship with your partner.

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Annals of Psychotherapy & Integrative Health HealthÂŽ

INTERPRETATION: The Empathy (E) scale of the RSM is a measure that is significantly related to relationship satisfaction and adjustment and reflects feeling sensitivity to the thoughts, emotions, and behaviors of others.

6. Drive Strength (DS) High Drive Strength (skill strength) indicates a skill and ability to effectively direct your energy to accomplish personal goals within your relationship with your partner. Low Drive Strength (skill change) indicates a lack of personal motivation and energy in the present and a perceived inability to accomplish meaningful personal goals. RSM Drive Strength (DS) is significantly negatively correlated to Neuroticism (r = -.41**) and significantly positively related to Extraversion (r = .39**) and Conscientiousness (r = .58**) as measured by the NEO. RSM Drive Strength (DS) is significantly positively correlated with Global Constructive Thinking (r = .32**), Behavioral Coping (r = .53**), Positive Thinking (r = .27*), Action Orientation (r =.46**) and Conscientiousness (r = .53**) as measured by the CTI.

INTERPRETATION: RSM Drive Strength (DS) is a measure of personal goal setting and achievement within your relationship. Drive Strength reflects focused and positive action to accomplish meaningful personal goals within a relationship context and is related to constructive thinking patterns. www.americanpsychotherapy.com

8. Time Management (TM)

Skill strength on this scale indicates your ability to initiate and follow through with effective problem solving and decision-making procedures in your relationship. A skill change may indicate difficulty in effectively solving personal and relationship problems in your current relationship with your partner. RSM Decision Making (DM) is significantly negatively correlated with Neuroticism (r = -.42) and significantly positively correlated with Extraversion (r = .37*) and Conscientiousness (r = .52**) as measured by the NEO. The RSM Decision Making (DM) scale is significantly positively correlated with relationship satisfaction and adjustment (r = .48**) as measured by the DAS. RSM Decision Making (DM) is significantly positively correlated with the CTI positive thinking scales of Global Constructive Thinking (r = .29**), Absence of Dwelling (r = .24*), Behavioral Coping (r = .51**), Positive Thinking (r = .26*), Action Orientation (r= .46**) and Conscientiousness (r = .53**).

Skill strength reflects your ability to effectively organize and use time in the present to accomplish relationship goals. A skill change indicates an inability to meaningfully organize time, difficulty in efficiently completing daily tasks, and a tendency to be overwhelmed by relationship responsibilities. RSM Time Management (TM) is significantly negatively correlated with Neuroticism (r = -.43**) and significantly positively correlated with Extraversion (r = .40**) and Conscientiousness (r = .62**) as measured by the NEO. Time Management (TM) as measured by the RSM is significantly positively correlated with the CTI positive thinking scales of Global Constructive Thinking (r =.25*), Behavioral Coping (r = .41**), Action Orientation (r = .39**) and Conscientiousness (r = .45**).

INTERPRETATION: RSM Decision Making (DM) is a measure of healthy personality, relationship satisfaction and adjustment, and constructive thinking patterns that involve effective and decisive problem solving skills.

9. Commitment Ethic (CE) Your score on this scale indicates your ability to follow through and complete tasks in a dependable manner. Skill strength reflects selfdirected and dependable behavior in completing personal responsibilities. A skill change indicates a tendency to begin projects without strong personal commitment and a lack of follow-through on personal and relationship projects. RSM Commitment Ethic (CE) is significantly negatively correlated with Neuroticism (r = -.45**) and significantly positively related to Conscientiousness (r = .55**) on the NEO. Commitment Ethic (CE) as measured by the RSM is significantly positively correlated with the CTI constructive thinking patterns of Global Constructive Thinking (r =. 29**), Behavioral Coping (r = .46**), Positive Thinking (r = .27*), Action Orientation (r = .42**), and Conscientiousness (r = .46**).

INTERPRETATION: RSM Commitment Ethic (CE) is a measure of your perceived ability to responsibly and dependably complete relationship responsibilities.

INTERPRETATION: RSM Time Management (TM) is a measure of your perceived ability to organize relationship responsibilities and complete them within a specified time frame.

10.Stress Management (SM) Skill strength indicates your ability to positively manage personal stress and anxiety. A skill change reflects a current inability to positively manage daily stressors and a tendency to develop negative (emotional and physical) reactions to life stress. RSM Stress Management (SM) is significantly negatively correlated with Neuroticism (r = .51**) and significantly positively correlated to Conscientiousness (r = .55**) on the NEO. Stress Management (SM) as measured by the RSM is significantly, positively correlated with relationship satisfaction and adjustment as measured by the DAS. RSM Stress Management (SM) is significantly positively correlated with all the positive thinking patterns measured by the CTI; Global Constructive Thinking (r = .43**), Emotional Coping (r = .36**), Absence of Negative Overgeneralizations (r = .28*), Non Sensitivity (r = .32**), Absence of Dwelling (r = .46**), Behavioral Coping (r = .36**), Positive Thinking (= .25*), Action Orientation (r = .36**) and Conscientiousness (r = .46**).

INTERPRETATION: RSM Stress Management (SM) is a measure of your ability to positively manage distress and to think constructively and behave effectively in high stress situations.

hese 10 RSM skill scales are significantly related and together provide a general factor measure of Emotional Intelligence (EI), resiliency, and relationship health and satisfaction. The congruent validation of RSM scale measures was an essential procedure in this study. Additional RSM research is needed to clarify the role of these healthy relationship skills in personal well-being. Relationship Satisfaction (RS): Your score on this scale reflects your current level of satisfaction with your relationship. Skill strength indicates personal satisfaction with your current relationship. A skill change indicates dissatisfaction and a focus on relationship problems. Intimacy (I): This scale reflects your current level of intimacy (emotional and physical comfort and closeness) in the relationship. Skill strength indicates satisfaction and personal comfort with the emotional and physical closeness in your relationship. A skill change indicates a perceived lack of emotional and physical closeness with your partner. The RSM scales of Relationship Satisfaction (RS) and Intimacy (I) provide valid measures of relationship satisfaction and adjustment. The RSM scale of Relationship Satisfaction (RS) is positively and significantly correlated with relationship satisfaction and adjustment as measured by the DAS (r = .73**). The RSM Intimacy (I) scale is significantly positively correlated with relationship and satisfaction as measured by the DAS (r= .83**). (800) 592-1125

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7. Decision making (DM)

CE ARTICLE: 1.5 CE Credits Scale by scale correlations of RSM scales with the NEO, DAS, and CTI are presented in the Professional Manual (Nelson, Nelson and Cox, 2010). Professionals using the RSM in clinical practice and research may consult the RSM Professional Manual to review the demonstrated psychometric parameters of the instrument and its established limitations and applications.

Method The purpose of the Scott & White Military Homefront Services Program was to design and deliver intervention strategies and resiliency skills training for military couples functioning in high-stress environments. In-depth and long-term psychotherapy or counseling was not feasible for this population because of the limitation of time resources. The resiliency skills training program was designed to promote emotional learning and specific relationship skills development. The RSM was used to engage participants by completing the instrument as a structured exercise in reflective thinking. Individual RSM profiles were constructed as a map or guide for targeted skill development, and a collaborative action plan was developed for each participant.

Participants The participants in the program were active duty military couples in the U.S. Army. All participants were facing frequent long-term deployments in war zones and functioning in a highly stressful environment. (See table 1, page 21) ANOVAs were used to compare each of the RSM scales to the means of the categories: No Children, Children Age 2-6, and Children Age 7-17. • For Self-esteem, Assertion, Comfort, Influence, Relationship Satisfaction, and Intimacy, the category Age 7-17 was significantly lower than either of the other two. • For Empathy, all three age categories are significantly different from each other. • For Decision Making, 7-17 is lower than 2-6, and Time Management also shows this pattern. • For Aggression, Deference, Change Orientation, Drive Strength, and Commitment Ethic, none of them are significantly different from the others. • For Stress Management, 7-17 is significantly lower than No Children. It does 20

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seem to indicate that teen-agers are more of a source of relationship stress than are younger children.

Instrumentation The Relationship Skills Map (Nelson and Nelson. 2009) was used as a positive selfassessment to identify the perceived relationship skill levels of the participants. The RSM is a valid and reliable instrument (Cox, 2010) and provides a measure of higher order thinking skills that are closely linked to constructive thinking patterns and skilled behaviors. Congruent validation studies with the RSM (Cox, 2010) indicate significant correlations with Behavioral Coping, Emotional Coping and Global Constructive Thinking as measured by the Constructive Thinking Inventory (Epstein, 2002). The RSM model of healthy relationships is an extension of the Transformative Theory of Emotional Intelligence (EI) (Nelson and Low, 2010) and provides a positive and practical method for quantifying resiliency skills in marital relationships. Doctoral research completed using the RSM has demonstrated that “distressed” couples (in counseling) achieve a significantly lower level of skills than do “non-distressed” couples (Webb, 1991). The major use of the RSM in this program was to provide a structured, reflective thinking exercise that linked participants’ perceived needs to specific skills contributing to resiliency in high stress environments. The RSM skills profile provided a cognitive model and common language between the therapists and the participants so that an individual action plan could be developed for each participant. Participants identified current relationship strengths and specific skills to learn, develop, and strengthen. The RSM is a sound psychometric instrument with acceptable levels of validity and reliability. More importantly the RSM is a positive-structured interview to engage the client in reflective thinking and personal goal setting. The results provide a map, or guide, for emotional skill development. The RSM is relationship oriented both in content and theory. It is the skill of the therapist and the quality of the relationships established with the participant that was the important consideration. The RSM is based on a relationship-focused and integrated theory of human behavior that is most closely related to Cognitive

Annals of Psychotherapy & Integrative Health®

Experiential Self-Theory (Epstein) and his extensive research on his central construct, global constructive thinking. Cognitive-Behavioral Techniques are often the treatment of choice for developing emotional self-control and stress management skills that build resiliency. The RSM skills profile provides a personal link between thinking patterns and behavioral skills that is meaningful to the individual completing the assessment.

Procedures The core-resiliency skills emphasized in the Scott & White Military Homefront Services Program were the 10 RSM skill scales of SelfEsteem, Assertion, Interpersonal Comfort, Empathy, Interpersonal Influence, Drive Strength, Decision Making, Time Management, Commitment Ethic and Stress Management. The program therapists developed an “RSM Tool Box” of cognitive behavioral interventions and experiential learning experiences to develop resiliency skills. A brief Self-Mentoring and Coaching Version of the RSM was developed based on a factor analysis (Cox and Cox, 2010) to improve the appropriateness of the instrument for program specific use. An integrated intervention program (The Relationship Enhancement Process) was developed that included constructive thinking, creative problem solving, and action goal setting.

Results The RSM was perceived as a valuable and helpful tool for identifying resiliency-skilldevelopment priorities. The major purpose of this action research study was to answer the question of how resiliency skills could be conceptualized and developed in a brief intervention program with distressed couples. The major perceived value of the RSM was that it linked participants’ perceived needs to specific resiliency skills. (See table 2, page 22) The Scott & White Military Homefront Services’ research sample differed significantly from the RSM standardization sample. The high stress environments experienced by these active duty military personnel are reflected in significantly lower scores in Self-Esteem, Interpersonal Comfort, Empathy, Drive Strength, Time Management, Commitment Ethic, Stress Management, Relationship Satisfaction, and significantly higher scores in Aggression and Change Orientation. The EI Total score comparison indicates that the Homefront www.americanpsychotherapy.com

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sample was significantly lower in EI skills (resiliency skills). The Relationship Total (Intimacy plus Relationship Satisfaction) indicates a significantly lower level of relationship satisfaction and adjustment in the Homefront sample. Therapists used the RSM profile results to provide effective emotional mentoring and positive support for the couples and to have a common language to construct strength-focused individual action plans for developing resiliency skills. The Self Mentoring and Coaching Version of the RSM was created to improve the quality of measurement provided by the instrument and to make administration and interpretation more consistent for use in self-directed coaching and emotional mentoring. Therapists of Scott & White Military Homefront Services provided valuable experiential exercises that liked the RSM measures to the development of specific cognitive/

Ta b l e 1

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8 16 68 8

HISPANIC BLACK OTHER INCLUDING WHITE

9 2 14

36 8 56

MARRIED SINGLE MISSING

21 3 1

84 12 4

PROTESTANT CATHOLIC OTHER

5 6 14

20 24 56

MALE FEMALE

13 12

52 48

YES NO N/A

11 9 5

44 36 20

0-20 21-30 31-40 41-50

1 17 6 1

4 68 24 4

Annals AnnalsofofPsychotherapy Psychotherapy&&Integrative IntegrativeHealthÂŽ Health

T N

FR 2 4 17 2

ANOVAs were used to compare each of the RSM scales to the means of the categories No Children, Age 2-6, and Age 7-17. For Self-Esteem, assertion, comfort, influence, relationship satisfaction, and intimacy the category Age 7-17 was significantly lower than either of the other two. For Empathy, all three age categories are significantly different from each other. For Decision Making, 7-17 is lower than 2-6, and time management also shows this pattern. For Aggression, Deference, Change Orientation, Drive Strength and Commitment Ethic, none of them are significantly different from the others. For Stress Management, 7-17 is significantly lower than No Children. It does seem to indicate that teen-agers are more a source of relationship stress than are younger children.

LESS THAN HS HIGH SCHOOL SOME COLLEGE BACHELORS DEGREE

N = 25 for Killeen Frequency Data RSM â&#x20AC;&#x201C; Data is for individuals not couples

TR M CA ED ES A T R O E SE U IT F G G CA D A E A O R N L D R EL TI CO ET D ST U IE O I E U LT S G H N A R P IO N T S LE LE U IC N V S S IT EL Y

HOMEFRONT SAMPLE: DEMOGRAPHICS

Demographics of the Homefront Research Sample

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Means, Standard Deviations, Standard Errors, & t Test for Equality of Means SCALE

Disst. a

STANDARD DEVIATIONS Soldier b Disst. a

MEANS Soldier b

SELF-ESTEEM

78.51

69. 80

10. 58

12. 9 5

ASSERTION

32.1 8

3 0.04

5. 38

6. 3 3

COMFORT

30.75

26. 16

4. 82

5. 37

EMPATHY

1 9.88

16. 36

3.46

4. 5 5

INFLUENCE

2 5.03

23.00

3. 26

5.45

DRIVE STRENGTH

4 3.51

38. 88

6. 36

6. 2 2

DECISION MAKING

21 .85

21. 76

3. 20

4. 24

TIME MANAGEMENT

20.4 5

16. 9 6

4. 35

4.60

COMMITMENT ETHIC

24 .91

22.6 0

3. 13

5.0 8

STRESS MANAGEMENT

61 .54

52.48

9. 77

9.66

RELATIONSHIP SATISFACTION

35.04

29. 88

6. 53

6. 87

INTIMACY

25.33

23. 80

4.69

5. 39

AGGRESSION

21 .85

30. 28

7.52

8. 39

DEFERENCE

21 .4 1

23.48

5. 70

8. 18

CHANGE ORIENTATION

1 7.29

21.00

4. 9 6

4. 52

358.62

318.04

41.55

54.39

10.77

11.74

EI TOTAL

60.37

RELATIONSHIP TOTAL a

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53.68

Dissertation group: N = 195

Annals of Psychotherapy & Integrative Health Health速

Soldier group: N = 25 df = 218

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D E V E LO P I N G R E S I L I E N C Y S K I L L S

NOTE: The Scott & White Military Homefront Services research sample differed significantly from the RSM standardization sample. The high stress environments experienced by these active duty military personnel are reflected in significantly lower scores in Self-Esteem, Interpersonal Comfort, Empathy, Drive Strength, Time Management, Commitment Ethic, Stress Management, Relationship Satisfaction and significantly higher scores in Aggression and Change Orientation. The EI Total score comparison indicates that the Homefront sample was significantly lower in EI skills (resiliency skills). The Relationship Total (Intimacy plus Relationship Satisfaction) indicates a significantly lower level of relationship satisfaction and adjustment in the Homefront sample.

STANDARD ERRORS OF MEAN Soldier b Disst. a

Resiliency skill training is a promising intervention strategy for protecting and strengthening the marital relationships of active duty military personnel facing frequent deployments to war zones. In this study, the RSM was found to be helpful in quantifying resiliency skills and providing a cognitive model for exploring, identifying, and understanding specific relationship skills that build resiliency in marital relationships.

SIG

MEANS DIFFER?

EQUAL VARIANCE ASSUMED?

. 76

2.59

3.774

0.000

YES

.38

1 .27

1 .839

0.067

YES

.34

1 .07

4 .430

0.000

YES

.25

.91

3.726

0.001

YES

.23

1 .09

1 .818

0.080

.4 6

1 .24

3.439

0.001

YES

.23

.85

0.122

0. 9 03

YES

.31

.92

3.752

0.000

YES

.22

1.02

2.222

0.035

YES

. 70

1 .93

4 .370

0.000

YES

.47

1 .37

3.701

0.000

YES

.34

1 .08

1 .5 13

0. 132

YES

.54

1 .68

- 5.209

0.000

YES

.4 1

1 .64

-1 .231

0. 229

.36

.90

-3.5 58

0.000

YES

4.426

0.000

YES

2.896

0.004

YES

2.98

.77

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10.88

2.35

Annals AnnalsofofPsychotherapy Psychotherapy&&Integrative IntegrativeHealth速 Health

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CE ARTICLE: 1.5 CE Credits behavioral skills in a practical and systematic emotional learning system. The use of the RSM results as a self-mentoring and coaching guide provided participants with a relationship-enhancement process that they could use daily. One of the primary goals of Scott & White Military Homefront Services was to provide emotional learning that could be transferred over time and distance. Many of the couples would be physically separated for months during deployment and needed specific ways to protect their relationship during stressful times.

Case Example: (Contrived Composite) Joe and Mary have been married 17 years— nine years as civilians, eight as military. Joe has been deployed three times to Iraq and once to Korea. His deployments were for 12 months, except for his second to Iraq which was for 15 months. Joe is on orders to deploy to Afghanistan in approximately four months from the date of the initial counseling intake. The couple have five children, ages 16, 14, 13, 11, and 5. Joe and Mary state that they are coming to marital counseling due to difficulties with communication and intimacy. Both state they believe they have had a good marriage and, in fact, state it was a “great marriage” prior to the last two deployments. Since that time, they say they are having “stupid” arguments and do not “feel as close.” The RSM was given to the couple as a tool to assist them in cognitively identifying areas of strengths and skills-development opportunities. Mary identified areas of development as self-esteem and interpersonal comfort. Joe identified areas of development as empathy and stress management. Both scored high on commitment ethic and overall relationship satisfaction. The therapist then utilized the scale definitions to explore with Joe and Mary their RSM scores. They were given a copy of each scored RSM to examine. Mary and Joe were asked to create a “Strategic Homefront Action Plan” and come to the next session with two ideas on how to assist their partner and one way they could help themselves with their self-identified area of development. The next two sessions were focused on the strategic plan for before, during, and after the impending deployment. Mary’s plan included a scheduled exer24

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cise time to increase her self-esteem and decrease stress. She stated that she realized she had stopped emotionally sharing with Joe because she did not want to “upset him,” and when she did talk to him about family issues, she was hesitant and unsure. Her plan was to talk with him in the mornings after PT when they drank coffee together, prior to the day starting. While Joe was deployed, she would e-mail him once a week with the family “growth opportunities” (therapist reframe) and family solutions. If there was time for suggestions, she would consult with him, if not, she would inform him of the action she had taken. After deployment, he would co-facilitate the family meetings that collectively identify and resource growth opportunities. Joe’s plan included a step that he would take before talking to Mary. He would think about how grateful he is that Mary has been a steady faithful partner and would remember how he felt the last time he was left to care for the five children while she went to visit her mother. Before deployment he would focus on what she had to say during morning coffee, after he exercised (PT). During deployment he would work to tell her how proud he was of her for doing all that needed to be done while he was gone and he would also share with her his sadness at not being there with her. After deployment he would remember morning coffee and turn off his phone, the television, and the computer while they talked. Joe’s stress-management-skills development was to listen to a relaxation CD every evening before, during, and after deployment. Joe also stated he was going to his unit’s stressmanagement-skills-development class. The fourth session was spent going through the skills they had identified as strengths and empowering them to communicate about the core feelings of sadness, fear, and uncertainty that they identified as a result of the back-to-back deployments.

Discussion Mental health professionals perceived the Relationship Skills Map (RSM) as a helpful reflective learning tool in Scott & White’s Military Homefront Services Program. The personal well-being of active duty military personnel serving in war zones is the priority of the U.S. Army. Resiliency skills training was the focus of this intervention program, and services were extended to couples

Annals of Psychotherapy & Integrative Health®

predeployment as well as postdeployment. The RSM skills profile of the couples served by the program indicated high levels of distress and an expressed awareness of the need for change and improvement in their relationships. This action research study answered the question of how to operationally define “resiliency skills” and how to implement a brief intervention program to protect and strengthen the marital relationship of active duty Army couples facing frequent and long deployment to war zones. It is important to note that the RSM was an effective tool in this process. The skill and the quality of the helping relationships created by the program therapists were the crucial factors in developing resiliency skills important to these highly stressed couples. Assessment instruments are crude and imperfect tools, and it is the skill of the professional using the instrument that is the most important variable in program effectiveness. Relationships that facilitate positive change provide protection, permission, and potency (empowerment). The Scott & White Military Homefront Services Program is an example of best practices for the use of the RSM. Collaborative research and practical feedback from the therapists improved the instrument, and the SelfMentoring and Coaching Version became a more useful tool in terms of measurement quality and ease of use. Traditional assessment approaches to personality and relationship adjustment tend not to provide results that can be translated into specific skill-building interventions. The RSM was designed for professionals and is continually strengthened by ongoing research. The major value and intended use of the RSM is as a personalized guide or map that an individual can follow in developing specific skills that contribute to relationship satisfaction and personal well-being. The RSM is a personal guide for emotional learning and relationship skill development and is not a “test.” The U.S. Army and Air Force spend millions of dollars on training and development. Resiliency training for active-duty military couples is an important and essential priority. There is a need to develop systematic intervention programs that can be evaluated, revised, and improved to improve the quality and effectiveness of services. This article describes a beginning attempt to personalwww.americanpsychotherapy.com

D E V E LO P I N G R E S I L I E N C Y S K I L L S ize resiliency training in a way that engages couples in active and focused skill development. The favorable acceptance and professional use of the RSM in the Scott & White Military Homefront Services Program is the first and important step in designing an intervention program that can be evaluated by a sound research design. The use of the RSM in the program is being expanded, and additional research and program development are in progress. The emphasis can now be placed on strengthening the intervention and skills-training exercises, with the aim of evaluating their effectiveness.

Recommendations The Scott & White Military Homefront Services Program is expanding services to meet the growing needs of active-duty Army couples who leave and return from long deployments in war zones. The effectiveness of the various skill-development interventions and training sequences need to be continually reviewed and evaluated in studies with sound designs. The best way to evaluate and demonstrate program effectiveness statistically is the use of an experimental design with adequate controls. Multiple outcome criteria should be used to demonstrate the effectiveness of the program in developing resiliency in marital relationships with prolonged exposure to high-stress environments. The RSM was an effective tool for identifying and operationally defining resiliency skills targeted as skill-development priorities in this program. Additional RSM research is needed to determine the predictive validity of the instrument in identifying marital couples in severe crisis who need more individualized and long-term therapy. Previous RSM research (Webb, 1991) has demonstrated the discriminate validity of the instrument in identifying general levels of distress in marital relationships. High scores on the RSM scales of Aggression, Deference, and Change Orientation are accurate indicators of problematic behaviors. High Aggression, accompanied by low skill scores on Empathy and Assertion, indicates the need for an individual to develop anger management, empathic communication, and empathy. High Change Orientation and Low Relationship Satisfaction indicate current dissatisfaction in the relationship and an awareness of the need to make changes. Additional research needs to be completed to determine the predictive (800) 592-1125

value of RSM problematic indicators and the significance of low skill scale scores. A very program-specific recommendation would be to use the RSM Form A as a pretest and RSM Form B (a parallel research form) as a post-test to indicate changes and gains in self-perceived relationship skills. Other outcome criteria such as Resiliency Scales and behavioral checklists completed by the therapists could be used to begin to examine program results and effectiveness. A sound experimental research design using valid and reliable instruments could be developed and implemented to statistically demonstrate program effects.

Concluding Statement The RSM proved to be a valuable and effective tool for operationally defining “resiliency skills” in the Scott & White Military Homefront Services Program. The collaborative research and program development activities completed as a part of the program led to improvement in the RSM (Self-Mentoring and Coaching Version) and the design of couple-specific relationship skill development activities to build resiliency. Well-designed research studies with multiple outcome criteria need to be completed to demonstrate the effectiveness of resiliency skills training for military couples facing high stress environments. This action research study was a first step in developing improved instrumentation and skill development interventions that are essential components in quality program design and delivery.

References Costa, P. T. & Mc Crae, R. R. (1992) NEO-PI-R, Professional manual, Lutz, FL: PAR Cox, J. (2010) Quantifying Emotional Intelligence in Relationships: The Validation of the Relationship Skills Map, Unpublished doctoral dissertation, Texas A&M University-Kingsville, Epstein, S. (2001) CTI/Constructive thinking inventory, Professional manual, Lutz, FL: PAR. Nelson, D. and Low, G. (2010) Emotional intelligence, achieving academic and career excellence. Upper Saddle River NJ. Prentice Hall. Nelson, D. & Nelson, K. (2010) The Relationship Skills Map, Emotional Intelligence Learning Systems, Corpus Christi, TX. Nelson, D., Nelson, K., & Cox, J. (2010) The Relationship Skills Map, Professional Manual, Emotional Intelligence Learning Systems, Corpus Christi, TX. Spanier, G. B. (2001) Dyadic adjustment scale, North Tonawanda, NY: MHS. Webb, J. B. (1991) Patterns of social skills in a typolo-

gy of marital systems. Unpublished doctoral dissertation, The Fielding Institute, Santa Barbara, CA. Wolin, S. J. & Wolin, S. (1993) The resilient self: How survivors of troubled families rise above adversity, New York: Villard Books. EARN CE CREDIT To earn CE credit, complete the exam for this article on page 75 or complete the exam oniine at www.americanpsychotherapy.com (select “Online CE”)

ABOUT THE AUTHORS

DARWIN B. NELSON

is an author and consulting psychologist who has created, researched, and published positive assessment instruments and emotional learning systems that are used worldwide for the assessment of Emotional Intelligence (EI) and healthy relationship skills.

KAYE WELCH NELSON Before her retirement this past summer, Kaye W. Nelson, EdD, was a Professor in the Department of Counseling and Educational Psychology at Texas A&M University-Corpus Christi where she served as Coordinator of the Couple, Marriage, and Family Counseling Program. She is a Clinical Member and Approved Supervisor in the American Association for Marriage Family Therapy and a Licensed Marriage and Family Therapist and Licensed Professional Counselor in Texas.

MAXINE E. TRENT, MS is the Program Manager at Killeen Mental Health Services and Scott & White Military Homefront Services. She received her Bachelors Degree in Human Development Family Studies from Texas Tech University and her Masters Degree in Science from Texas A & M Corpus (previously Corpus Christi State University). She has been blessed with 20+ years of therapy skill development in which to draw from, in partnering with clients and families whom seek new solutions to old problems.

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f l e l s a e c i h t holog c y s p ent m r l o of t logica e s sen sycho intere l p h d t f the aviora specn a o r ) CD much d beh cal pe ment O ( i n t der While rrors a holog d trea self r o m e n yc er. dis ve isord nking elf ps tion a pts fro llowi s l s i d a u e fo mp to this hic th rom a tualiz conc d his tions o c o p g n ep rf sive lation tastro sorde conc oratin 77) a 971) n cits in s e e 9 a r fi e c 1 (1 f bs rp di s o ced in dress s the hat th inco 1971, hutâ&#x20AC;&#x2122;s on de ure o e s s y t t ( o e d g n iscu perie ts to a explor tion is pon b ohut d to K cusin ive na l from d i x t K u y a p e e ria , fo ra cle le en arti often attem s artic l cont anded ted b ill be ptment resto mate ate th s i Th hat is ture s, thi ntra exp ulga n w trea the inical llustr ice. A i e e l t itera ion t d io d l ent The c can b y, prom ttent gy an es an nce. C rther prac prev ive. CD log lar a olo enc ere ll fu y to D is i i o r t f O ho icu ath f o syc Part op exper trans ase w l theo or OC psych o f t h p rs. f t c a t e f psyc objec -objec inical clinic work sion o effort e e l o elf- self f c u an en s he i le c n o ram incl t ing licatio tual f h the pts in exper ofs d a pp e t a oncep ed wi conc p the nt an s in e s c ent ytic s nal er gra r torm ration sye p a ett b f inne consid to c a l o er i f elation l o g nt. r o e c h reatm t

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CE ARTICLE: 1 CE Credit This article is approved by the following for 1 continuing education credit: The American College of Forensic Examiners International is an NBCC-Approved Continuing Education Provider (ACEP™) and may offer NBCC-approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program. The American College of Forensic Examiners International is an approved provider of the California Board of Behavioral Sciences, approval PCE 1896. Course meets the qualification for 1 hour of continuing education credit for MFTs and/or LCSWs as required by the California board of Behavioral Sciences. The American Psychotherapy Association® provides this continuing education credit(s) for Diplomates and certified members, who we recommend obtain 15 credits per year to maintain their status. LEARNING OBJECTIVES: 1. Describe how three different models, namely neurobiological, cognitive-behavioral, and psychodynamic, attempt to explain the etiology of OCD. 2. Analyze how to diagnostically differentiate OCD from three disorders with similar features, specifically generalized anxiety disorder (GAD), obsessive-compulsive personality disorder (OCPD), and the paraphilias. 3. Identify how to apply concepts from self psychology to the conceptualization and treatment of OCD. KEYWORDS: obsessive-compulsive disorder, psychopathology, selfobject theory TARGET AUDIENCE: professional counselors, psychologists, and psychiatrists PROGRAM LEVEL: intermediate DISCLOSURES: The authors have nothing to disclose. PREREQUISITES: A basic anxiety course and/or a basic understanding of psychoanalysis/ psychodynamic theory

A SELF PSYCHOLOGICAL VIEW OF OBSESSIVE-COMPULSIVE DISORDER: TREATING THE TORMENTED SELF Why is it that some of us think the unthinkable? How is it that some people can dismiss disturbing thoughts as irrational, while others are plagued by a sense of danger or harm? Poe called it “the imp of the perverse,” noting that there is an unconquerable force that impels us to think what we should not think (Poe, 1984). It is striking how Poe was able to capture a universal human condition in his experience of the unthinkable. We might all entertain disturbing thoughts from time to time, but when the thoughts become intense and intrusive, and our behaviors turn into all-consuming rituals that are executed to rid us of fear and dread, then we are suffering from obsessive-compulsive disorder (OCD) (Schwartz, 1996). Clearly, the individual does not wish for the thought to revisit so hauntingly and persistently, yet the person’s best efforts to ignore it are not a sufficient barrier to continue the process of living normally without such hounding. How can we better understand obsessional thinking and OCD? Particularly, what does a self psychological perspective offer in terms of adding to dimensions of this disorder that may be otherwise neglected? This article will present material related to a patient who suffers from obsessive-compulsive disorder. The discussion will begin by defining obsessive-compulsive disorder and attempting to view the disorder as an effort to deal with anxiety. Three frameworks for understanding OCD will then be provided: the neurobiological model, the cognitive-behavioral model, and the self psychological model. The focus will then shift from theory to the case material, which will include a brief description of the patient’s symptom picture, a summary of the clinical issues, and a description of her response to treatment. The discussion will touch upon some of the major tenets of self psychology as aspects of the material were viewed through this conceptual lens. Some of the limitations of the cognitive-behavioral approach will be addressed in this context. Attempts will be made to develop a conceptual framework for OCD with the inclusion of psychoanalytic concepts and to offer clinical considerations in relation to its psychological treatment. 28

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DEFINING OCD When anxiety becomes a prominent feature of someone’s psychological problems, and when it is extreme, it can be considered a disorder. Karen Horney’s Drive Reduction Theory describes the need for the body to maintain a certain level of arousal that creates a sense of homeostasis or balance (as cited in Morris & Maisto, 2005). Anxiety sufficient to produce alertness for examination is beneficial, whereas anxiety carrying an individual to extremes in thoughts, feelings, and behaviors puts the person at risk of maladaptive internal and external experiences. People with OCD grapple with a neurobiological disorder that consumes their minds with unwanted thoughts and threatens them with dread if they fail to act upon senseless, repetitive rituals. About one in 40 people suffer from OCD. The Obsessive-Compulsive Foundation website states that there are approximately 5 million Americans who suffer with the disorder (www.ocfoundation.org). The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th Edition—Revised (2000, DSM-IV-TR) defines obsessions as “persistent and recurring thoughts, ideas, images, or impulses that are experienced as intrusive and inappropriate, that are not simply excessive worries about real-life problems, and that cause marked anxiety or distress (e.g., thoughts of killing a child, becoming contaminated). The person recognizes that they are the product of his own mind and attempts to suppress or ignore the obsessions or neutralize them with some other thought or action” (p. 422). Compulsions are defined in the DSM-IV-TR as “repetitive behaviors (e.g., checking the stove, hand washing) or mental acts (e.g., praying silently, counting numbers) that the person feels driven to perform in response to the obsession or according to rigid rules. The compulsion is aimed at preventing or reducing distress or preventing some dreaded situation; however, the compulsions are either unrealistic or clearly excessive” (p. 423). Additionally, OCD can be differentiated from paraphilias, substance abuse, and pathological gambling in that the latter disorders are associated with the anticipation of pleasure and satiation (Hyman & Pedrick, 2005). www.americanpsychotherapy.com

A S E L F P S YC H O L O G I C A L V I E W O F O B S E S S I V E - C O M P U L S I V E D I S O R D E R Obsessions can be grouped according to the following categories: obsessions about dirt and contamination, obsessive need for symmetry or order, obsessions about hoarding or saving, obsessions with sexual content, repetitive rituals, religious obsessions (scrupulosity), obsessions with aggressive content, and superstitious fears. Compulsions can also be grouped accordingly:

cleaning and washing compulsions, compulsions about having things “just right,” hoarding or collecting compulsions, and checking compulsions (Schwartz, 1996). Ambivalence and doubt are the hallmarks of this type of thinking. OCD is distinguished from generalized anxiety disorder (GAD) in that GAD is characterized by excessive worry about re-

al-life situations. Although obsessive-compulsive personality disorder (OCPD) and OCD have similar names, OCPD is not characterized by obsessions and compulsions and instead involves a pervasive pattern of preoccupation with orderliness, perfectionism, and control, and must begin by early adulthood. Unlike people diagnosed with OCPD, those with OCD are aware

one in People with OCD grapple with a neurobiological disorder that consumes their minds with unwanted thoughts and threatens them with dread if they fail to act upon senseless, repetitive rituals. (800) 592-1125

people suffer fromOCD

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Neurobiological Theory When these centers are overactive, the individual gets stuck on certain behaviors, thoughts, and ideas.

of their irrational thinking and are ashamed and embarrassed by this pattern (Schwartz, 1996).

THEORIES OF OCD NEUROBIOLOGICAL THEORY Despite the fact that it is beyond the scope of this article to provide a thorough discussion of the neurobiological mechanisms of OCD, a brief discussion of some biological findings follows. Positron emission tomography, or PET scans, show increased energy use in the orbital cortex, the underside of the front of the brain, in persons with OCD (Schwartz, 1996). Brain imaging studies have shown that several parts of the brain are involved with OCD, specifically, the thalamus, caudate nucleus, orbital cortex, and cingulate gyrus (Hyman & Pedrick, 2005). Magnetic resonance imaging (MRI) also reveals a larger cortex. The thalamus is the part of the brain that processes sensory messages coming to the brain from the rest of the body. The caudate nucleus is part of the basal ganglia, which controls the filtering of thoughts. The orbital cortex is the area where thoughts and emotions come together. The cingulated gyrus helps shift attention from one thought or behavior to another. When these centers are overactive, the individual gets stuck on certain behaviors, thoughts, and ideas. In other words, the alarm system of the brain has gone awry, leading to neurobiological dysregulation (Hyman & Pedrick, 2005).

THE COGNITIVE-BEHAVIORAL MODEL Much of the literature attests to the effectiveness of Cognitive-Behavioral Therapy (CBT) for OCD (Foa & Wilson, 1991; Hyman & Perdrick, 2005; McGinn & Sanderson, 1999). The cognitive models address the thoughts and beliefs that serve to create and maintain the OCD symptoms. Persons with OCD attribute catastrophic meaning to their unwanted thoughts. CBT is a short-term, symptom-focused treatment 30

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